Measles Exposures in Central & South-Central Texas

Multiple health departments in Central and South-Central Texas recently reported measles exposures associated with the ongoing outbreak in the South Plains region of Texas. Healthcare providers in Central and South-Central Texas are asked to review the information in this alert and be vigilant for cases of measles resulting from these exposures.

DSHS advises clinicians to immediately report any suspected cases to your local health department, preferably while the patient is in your presence.

A measles outbreak centered in West Texas continues to grow. That outbreak was the subject of a DSHS health alert on Feb. 5, and the latest information on it is available in a DSHS News Update. A person from the outbreak area who was later diagnosed with measles visited locations in the San Marcos and San Antonio areas the weekend of Feb. 14-16 while they were contagious. A measles exposure may have occurred at the following times and locations:

Friday, Feb. 14

• 3 to 7 p.m. – Texas State University, San Marcos
• 6 to 10 p.m. – Twin Peaks Restaurant, San Marcos

Saturday, Feb. 15

• 10 a.m to 4 p.m. – University of Texas at San Antonio Main Campus
• 2:30 to 7:30 p.m. – Louis Tussaud’s Waxworks, Ripley’s Believe It or Not!, and Ripley’s Illusion Lab, San Antonio
• 6 to 10 p.m. – Mr. Crabby’s Seafood, Live Oak

Sunday, Feb. 16

• 9 a.m. to 12 noon – Buc-ee’s, New Braunfels

The measles virus can survive in the air for up to two hours, so the times listed include two hours after the individual left that location. Because measles symptoms can begin 7 to 21 days after an exposure, DSHS is sharing this information with health care providers and the public in the area so unvaccinated people may monitor themselves for symptoms and seek testing if symptoms occur. More information on the possible exposures is available from Hays County Health Department, San Antonio Metro Health District, and Comal County Public Health.

Measles is a highly contagious respiratory illness. The virus is transmitted by direct contact with infectious droplets or by airborne spread when an infected person breathes, coughs, or sneezes. Measles virus can remain infectious in the air for up to two hours after an infected person leaves an area. Illness onset (high fever, cough, runny nose, and red, watery eyes) begins a week or two after someone is exposed. A few days later, the telltale rash breaks out as flat, red spots on the face and then spreads down the neck and trunk to the rest of the body. A person is contagious about four days before the rash appears to four days after. People with measles should stay home from work or school during that period.

The best way to prevent getting sick is to be immunized with two doses of a vaccine against measles, which is primarily administered as the combination measles-mumps-rubella (MMR) vaccine. Two doses of the MMR vaccine are highly effective at preventing measles. Some vaccinated people can occasionally develop measles; however, they generally experience milder symptoms and are less likely to spread the disease to other people. DSHS and CDC’s Advisory Committee on Immunization Practices (ACIP) recommend children receive one dose of MMR vaccine at 12 to 15 months of age and another at 4 to 6 years. Each MMR dose lowers the risk of infection and severity of illness if infected. Children too young to be vaccinated are more likely to have severe complications if they get infected with the measles virus.

Healthcare providers should consider measles in patients presenting with the following symptoms, particularly those who have traveled abroad or had contact with known measles cases:

• Fever ≥101°F (38.3°C) AND
• Generalized maculopapular rash lasting ≥3 days AND
  • Rash usually begins at the hairline/scalp and progresses down the body
• Cough, runny nose, or conjunctivitis OR Koplik spots (bluish-white specks or a red-rose background appearing on the buccal and labial mucosa usually opposite the molars).

Immediately report any suspected measles cases to your local health department (contact information below). If possible, please report while the patient is present to facilitate testing and the public health investigation, including follow-up of potential exposures.

Diagnostic Testing

Testing for measles should be done for all suspected measles cases at the time of the initial medical visit:

• DSHS strongly encourages providers to submit specimens for PCR testing to the DSHS Laboratory because genotyping will be performed on positive PCR specimens, which can be helpful during outbreaks.
• The DSHS Laboratory can perform PCR testing on throat swabs (preferred) or nasopharyngeal swabs placed in viral transport media and serology on serum specimens.
• Measles PCR and serology (IgM and IgG) testing is available at both the DSHS Laboratory and at commercial laboratories.
• Providers must contact their local health department or DSHS regional office to coordinate testing at the DSHS Laboratory to ensure specimens are submitted correctly and meet testing requirements.
• Unless coordinated in advance, specimens may only be received by the DSHS Laboratory during normal business hours Monday through Friday.

• MMR Vaccine
  • The best defense against getting sick is to be immunized with two doses of a vaccine against measles such as MMR vaccine.
• Post-Exposure Prophylaxis (PEP)
  • MMR vaccine, if administered within 72 hours of initial measles exposure, may provide some protection, or modify the clinical course of disease among susceptible persons who otherwise have no contraindications to MMR vaccination (e.g., severe immunocompromise, age <6 months, pregnancy). (cdc.gov/surv-manual/php/table-of-contents/chapter-7-measles.html). Providing MMR vaccine within 72 hours should be focused on people unvaccinated and people with one dose of MMR vaccine.
  • Susceptible persons who receive a dose of MMR vaccine as PEP within 72 hours of initial measles exposure may return to childcare, school, or work.
  • Children 6 months to 12 months of age may be given one dose of MMR if exposure occurred within 72 hours. Any susceptible contact between 6 months and 12 months of age who receives MMR vaccination should follow the CDC’s recommended schedule, as mentioned above. Children less than 6 months of age are not recommended to receive an MMR vaccine.
  • For people who are fully vaccinated with two doses of MMR vaccine or have measles infection documentation, a dose of MMR vaccine is not recommended.
• Immunoglobulin (IG)
  • IG, if administered within six days of initial measles exposure, may provide some protection against measles or modify the clinical course of disease among susceptible persons (cdc.gov/surv-manual/php/table-of-contents/chapter-7-measles.html). IG is available to be given intramuscularly (IGIM) or intravenously (IGIV). Depending on the patient’s personal medical history and time from exposure, IG may or may not be recommended.
  • IG is the only option for PEP for populations that cannot receive MMR vaccine (infants less than six months of age, severely immunocompromised people, and pregnant women).
  • Priority should be given to persons exposed in settings with intense, prolonged, and close contact (e.g., household, daycare, classroom) and for those at high risk of severe disease. IG PEP should be provided to severely immunocompromised contacts regardless of prior measles vaccination status due to the risk for severe disease.
  • IG PEP can be given to susceptible infants aged 6–12 months, although MMR vaccine is preferred per American Academy of Pediatrics (AAP) guidance if received within 72 hours of exposure.
  • IG can be obtained at a local hospital or through public health departments.

Controlling Outbreaks in Group Settings

• People with confirmed or suspected measles should stay home from school, work, and other group settings until after the fourth day of rash onset.
• During an outbreak, people without documented immunity from vaccination or previous measles infection should be isolated from anyone with measles to protect those without immunity and control the outbreak. Additional information on school exclusion and readmission can be found at School Communicable Disease Chart.
• According to the Texas Administrative Code (TAC) Rule §97.7, schools and childcare settings shall exclude unimmunized children for at least 21 days after the last date the unimmunized child was exposed to a measles case.

If you think you have measles or have been exposed to someone with measles, isolate yourself from others and call your healthcare provider before arriving to be tested so they can prepare for your arrival without exposing other people to the virus. Measles is extremely contagious and can cause life-threatening illness to anyone who is not protected against the virus. Review your and your child’s vaccination history to see if you are up to date on your measles vaccines. Additionally, discuss with your provider your vaccination history and any questions about these vaccines.

Find the public health reporting contacts for other counties.

• For Healthcare Professionals – Clinical Overview of Measles
• Interim Measles Infection Prevention Recommendations in Healthcare Settings | CDC
• Measles Infection Control in Healthcare Personnel | CDC
• Acceptable Presumptive Evidence of Immunity to Measles | MMWR
• ACIP Recommendations: Measles, Mumps and Rubella (MMR) Vaccine
• Measles – Manual for the Surveillance of Vaccine-Preventable Diseases | CDC
• Plan for Travel – Measles | CDC
• Laboratory Testing for Measles | CDC
• Measles Serology Testing | CDC
• CDC Measles Resources
• Global Measles Outbreaks | CDC